Robotic-assisted surgery in live-donor uterus transplantation
2018; Elsevier BV; Volume: 109; Issue: 2 Linguagem: Inglês
10.1016/j.fertnstert.2017.12.007
ISSN1556-5653
AutoresMats Brännström, Pernilla Dahm‐Kähler, Niclas Kvarnström,
Tópico(s)Organ and Tissue Transplantation Research
ResumoThe video by Fornalik and Fornalik on robotic-assisted uterus transplantation (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) is of interest in the developing field of uterus transplantation (UTx). It relates to infertility treatment of women with absolute uterine factor infertility, with either uterine absence (congenital/surgical) or abnormalities (anatomic/functional) that impede implantation of an embryo or completion of a pregnancy. This condition has been untreatable until recently; in our report of a birth occurring in 2014 (2Brännström M. Johannesson L. Bokström H. Kvarnström N. Mölne J. Dahm-Kähler P. et al.Live birth after uterus transplantation.Lancet. 2015; 385: 607-616Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar), UTx proved to be an effective treatment. This was followed by seven additional births from a cohort of seven women who underwent IVF followed by UTx and then embryo transfer (ET) after a post-transplantation period of 12 months (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar). In the Swedish trial, the clinical pregnancy rate and take-home-baby rate among the seven women who also underwent ET were as high as 100% and 87%, respectively. Thus, this novel fertility treatment is here to stay although it has to be developed further to make it safer and even more effective. Any clinical introduction of UTx in a center should be within a registered clinical trial and should follow the criteria for introduction of novel surgical procedures according to the IDEAL consortium (4McCulloch P. Altman D.G. Campbell W.B. Flum D.R. Glasziou P. Marshall J.C. et al.No surgical innovation without evaluation: the IDEAL recommendations.Lancet. 2009; 374: 1105-1112Abstract Full Text Full Text PDF PubMed Scopus (1191) Google Scholar). Thus, team preparation via animal models is important, and sheep are the recommended animal model based on our accumulated experience and training sessions with foreign teams. The first clinical UTx trial (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar) involved live donors (majority mothers), and the surgeries in both donors and recipients were with classic laparotomy techniques through midline incisions. The surgery was performed with minimal tissue trauma and bleeding, which was aided by the surgeons using magnifying loupes. Although the donors recovered from surgery fast and went home on postoperative day 6, a major concern was the rather long duration (10.5 to 13 hours) of the donor surgery—more than twofold longer than the recipient surgery. The long duration of open surgery increases the risk of postoperative complications such as bowel paralysis, wound infection, and perioperative and postoperative thromboembolism, although none of these occurred in our trial. There is a need for meticulous vascular dissection in the donor to achieve transplantable vessel pedicles without endangering the adjacent tissue, such as the ureter. In our practice, the most time-consuming part of donor surgery was dissection of the uterine veins, particularly in the area where they override and underride the ureters. The uterine veins are made up of two to three separate veins that come from the uterine body and then may converge into a common major uterine vein or have separate inlets into the internal iliac vein. Moreover, the individual variations concerning the veins with plexuses around the ureters are immense. The surgical procedure to dissect these vessels is complex because they are very closely attached to the ureters, with an absence of proper dissection planes and with multiple branches to the bladder, vagina, and between each uterine vein. Laparoscopic techniques may aid in the deep pelvic dissection in the donor surgery, and robotic-assisted laparoscopic surgery may be even more helpful due to the distally wristed instrument and precise movements in comparison with conventional laparoscopy when performing surgeries in narrow, complex spaces such as the deep pelvic cavity. To our knowledge there are two groups worldwide that have applied the robotic-assisted laparoscopy technique in UTx surgery, one Chinese group (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar), and our Swedish UTx team (our unpublished observations). The 12th UTx attempt in the world was by robotic-assisted laparoscopy uterine retrieval in late 2015 in Xia, People's Republic of China (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar). A 42-year-old mother donated her uterus to her 22-year-old daughter who had Mayer-Rokitansky-Küster-Hauser syndrome. The surgery followed the general principles used in the Swedish trial (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar) but with one major difference. The secured uterine outflow was through the utero-ovarian veins because the uterine veins were found to be excessively difficult to identify and to dissect unattached and intact from the surrounding tissues. The use of the utero-ovarian veins necessitated oophorectomy, which is not without medical consequences in a woman who may be a decade away from menopause. The surgical duration in the donor was 6 hours, which was half of the time used in our laparotomy approach (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar). The retrieval of the graft was through the vagina. The recipient surgery was by laparotomy, with bilateral end-to-side anastomosis to the external iliac vessels (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar). The duration of the recipient surgery was two times that of the Swedish trial (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar), which may indicate that the anastomosis of the utero-ovarian veins, with minimal thickness of the vascular walls, was far more difficult than when using a patch/segment of the internal iliac vein as in our experience by laparotomy (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar). In the Chinese robotic-assisted laparoscopic approach (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar) spontaneous menstruation resumed within 2 months after transplantation, and during the initial post-transplantation year 10 spontaneous menses occurred. The patient only experienced one rejection episode (after 2.5 weeks), which was diagnosed by clinical symptoms (low back ache, fatigue, and fever) and confirmed by an increased CD4/CD8 ratio. The rejection resolved by intravenous corticosteroid treatment for 3 days. We await reports on the results of ET attempts that were planned to start 1 year after UTx. In 2017 our team completed two live donor UTx procedures with the robotic-assisted laparoscopy procedure in the donor (our unpublished observation). Prior to that, we had clinical experience in robotic surgery, gynecologic-oncology surgery, and liver surgery. It is clear from our experience and in the video (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) that the robotic-assisted laparoscopy approach is advantageous in dissection in the deep pelvis. The authors of the video article (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) are in gynecologic-oncology practice and have experience in robotic-assisted radical hysterectomy procedures, with 60 cases of this procedure with a nerve-sparing technique. In this latter technique, the major autonomic nerves of the pelvis, including the hypogastric nerves, pelvic splanchnic nerves, and the pelvic plexus with its vesical branches, are spared to minimize postoperative dysfunction of the bladder or rectum. In the video the authors aim to demonstrate robotic dissection of uterine vessels and its application for uterine harvesting in live donor UTx. Concerning the uterine arteries and inflow to the uterus, due to the large vessel dimensions and the thickness of the vessel walls the vascular tree is fairly easy to dissect if there are no surrounding adhesions or fibrosis. In the video (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) it is suggested that patches of the internal iliac artery could facilitate blood flow to the uterus after transplantation. In our experience (3Brännström M. Johannesson L. Dahm-Kähler P. Enskog A. Mölne J. Kvarnström N. et al.The first clinical uterus transplantation trial: a six months report.Fertil Steril. 2014; 101: 1228-1236Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar) we always use major parts of the anterior branch of the internal iliac artery when harvesting the uterus in live donor cases, but sparing the major posterior branch on each side to avoid gluteal ischemia. The anterior branch is then used for end-to-side anastomosis to the external iliac artery of the recipient. Thus, the suggestion by the authors (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) of using a patch instead would not change common practice in UTx. Moreover, direct anastomosis of the small lumen (1–3 mm) uterine artery has not been used in any of our human cases so far. The authors state that the robotic approach provides an "unparalleled ability to dissect uterine vessels" (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar). We agree with the authors about the uterine arteries and the internal iliac vessels because this has been our experience as well in our two robotic UTx cases. With the robotic approach the large branches of the internal iliac arteries and veins can easily be dissected, and transection can be done after appropriate hemostasis on both sides. We prefer use of locking plastic hemoclips that are secured by single sutures for these large vessels. However, the most difficult part of vascular dissection at uterine harvesting is not shown in the video or discussed. That is the dissection to detach the veins from the ureters and from the vaginal wall between the inlet of the ureter into the bladder and the crossing of the uterine artery and the ureter. This has to be done without injuring the vessels and in particular the veins. Several small branches from the uterine veins must be severed, and this is complicated by the thin vessel walls and by the major uterine veins having to be fully preserved. In our two robotic cases, the dissection of the larger blood vessels were by the robotic approach, which is in line with our step-by-step approach and has been typical for our decade of animal research on UTx. The most difficult dissection has so far been performed with classic techniques after conversion to laparotomy. The research protocol in our clinical trial of 10 robotic cases was to do progressively more of the surgery by robotic approach. We agree with the authors (1Fornalik H. Fornalik N. Uterus transplantation: robotic surgeon perspective. Suggestions from gynecologic oncology experience on deep pelvic dissection and wider vascular anastomoses.Fertil Steril. 2018; 109: 365Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) that in the future a fully robotic approach for uterine harvesting may be used and that the uterus with vasculature can be extracted vaginally, preferably by covering the vaginal mucosa with a plastic device and then placing the uterus in a sterile bag, which is the approach described in the video. It should be pointed out that in the Chinese case (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar) vaginal extraction was used but the uterine graft was extracted through the vagina without any barrier to bacterial contamination. There are no reports of infectious processes within that graft (5Wei L. Xue T. Tao K.S. Zhang G. Zhao G.Y. Yu S.Q. et al.Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months.Fertil Steril. 2017; 108: 346-356Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar), but we nevertheless do not think that such an extraction is advisable. The authors conclude that "high-volume robotic gynecologic oncology regularly performing nerve sparing radical hysterectomies have the best chances to adapt uterine harvesting to robotic techniques." We do not fully agree with this because we think that ample experience in robotic pelvic lymph-node dissection and radical hysterectomy is the most important part of experience for the gynecologic surgeon, but it may not automatically provide the necessary skills for harvesting the delicate veins without injuring the vessels or the donor. These skills may be accomplished by setting up a complete surgery team including transplant surgeons and training in large animals models of UTx. The crucial part is to have a fully integrated team of gynecologic-oncology surgeons and transplant surgeons. Concerning the robotic approach, the transplant surgeons should also have experience in robotic surgery, now used more frequently in donor nephrectomy and in liver surgery. Finally, and importantly, the end point of having a healthy child born from a transplanted uterus should not be forgotten while the surgical technique evolves and progresses. Uterus transplantation: robotic surgeon perspectiveFertility and SterilityVol. 109Issue 2PreviewTo study the safety and feasibility of robotic dissection of deep pelvic vessels as applied to the robotic harvesting of a uterus from live transplant donor. Full-Text PDF
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